Healthcare Provider Details

I. General information

NPI: 1366228348
Provider Name (Legal Business Name): SAMUEL C KIM NEUROLOGICAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2023
Last Update Date: 08/27/2024
Certification Date: 08/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13677 W MCDOWELL RD
GOODYEAR AZ
85395-2635
US

IV. Provider business mailing address

2415 E CAMELBACK RD STE 700
PHOENIX AZ
85016-4245
US

V. Phone/Fax

Practice location:
  • Phone: 424-443-4749
  • Fax: 951-667-7786
Mailing address:
  • Phone: 424-443-4749
  • Fax: 951-667-7786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SANDY KIM
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 424-443-4749